Transitioning Patients to Independence.

Approximately one in four to five patients discharged from the hospital is rehospitalized within 30 days. Through the Grotta Fund for Senior Care, we implemented a program to address rehospitalizations among patients with chronic conditions including congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus. Patients were introduced to telehealth by a transitions coach while still in the inpatient setting. Patients received three coaching visits, daily monitoring of vital signs, and daily monitoring for signs/symptoms of exacerbation. Patients were educated on disease-specific red flags, participated in role playing, and received two visits with a dietitian who went grocery shopping with them. The 30-day rehospitalization rate for patients participating in the program (n = 102) was 7.8%. The number of hospitalizations in the 90 days prior to the program totaled 126. This was compared with 36 hospitalizations in the 90 days after admission to the program. The Wilcoxon T+ test shows there is a statistically significant difference in the number of hospitalizations (p < .0001). Giving chronically ill patients the tools and support to become independent in their care was shown to decrease hospitalizations.